Why one top hospital is going public with its mistakes

Hospitals celebrate their safety records, but rarely discuss their mistakes. Yet it’s difficult, if not impossible, to improve safety without identifying and learning from errors. That’s why Brigham and Women’s Hospital has launched Safety Matters. This blog aims to describe mistakes made at the hospital along with steps the hospital is taking to prevent them in the future.

The current entries cover medication errors, delayed diagnoses, incorrect use of an intravenous line, and other problems that harmed, or could have harmed, a patient. Each article describes an error, how it came to light, and the steps taken to prevent it from happening again. When possible, it also includes comments from the patient who was on the receiving end of the error, and possibly his or her family members. The patient story is pivotal because it lets care providers understand how mistakes affect the lives of patients and their family members.

Take, for example, the story of a delayed cancer diagnosis in an 85-year-old woman who was being followed for a seemingly benign growth in one of her lungs. Her primary care physician asked her to have an X-ray to check the nodule. It showed suspicious growth, so the woman had a CT scan to better assess the growth.

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The radiologist sent the CT results — which indicated probable lung cancer — to the primary care provider, but didn’t include a separate note warning of an abnormal finding, assuming that the primary care physician was aware of the CT result. But the primary care physician overlooked the CT report and didn’t act on it until noticing the report five months later during a follow-up visit with the patient. A new CT scan showed further progression of lung cancer. The primary care physician told the patient about the error and apologized. Her cancer was treated, but she passed away about a year later. Although the delay probably did not affect her outcome, it was important to us — and to the patient’s daughters — that we do everything in our power to prevent this from happening to someone else.

After the error came to light, the woman was invited to attend the Brigham’s Morbidity and Mortality Rounds to share her story. The event, her description of it, and the perspectives of the clinicians involved helped change how the hospital communicates clinically significant test results. “My mother would be happy to know if this makes a difference for somebody else,” said one of her daughters in a Safety Matters report.

Focus on solutions

We began Safety Matters in 2011. At the time, it was an internal communication available only to Brigham and Women’s employees via the hospital’s intranet. One goal is to make sure that everyone on the staff knows that the hospital is committed to being open and transparent about mistakes and learning from them. Another goal is to convey that reporting mistakes is not only encouraged, but is also the right thing to do.

Another element of some blog entries is the “Just Culture Corner.” It helps promote a culture in which hospital staff and patients feel safe and supported when speaking up about mistakes and risks.

Why we went public

Safety Matters went public in January 2016. We did this for several reasons:

It’s now more accessible to the entire staff, and can be read from home or a mobile device.

It demonstrates to patients, prospective patients, and other stakeholders that the hospital is committed to transparency and continuous improvement.

It can be a resource for other hospitals in the United States and around the world to provide safer patient care.

The same errors that happen at the Brigham happen at other hospitals. But the Health Insurance Portability and Accountability Act (HIPAA) and legal issues can make it tough for a safety specialist like me to discuss the specifics of a case with a colleague at another hospital. Safety Matters meets HIPAA’s privacy standards because we get permission from the clinicians and patients involved in a case before we publicly discuss it.

The feedback we have received from individuals inside and outside the Brigham has been overwhelmingly positive. A number of other hospitals have reached out to ask about the steps needed to launch their own efforts to openly talk about mistakes and solutions. That could become an excellent forum through which we could all learn from each other.

We work hard to make sure that Brigham and Women’s Hospital provides the safest and highest-quality care possible. One way to underscore our commitment to that is to identify when we don’t meet that standard and show what we are doing to fix the problem. Safety Matters is an important way to do that.

Karen Fiumara, PharmD, is senior director of patient safety at Brigham and Women’s Hospital in Boston. She oversees Safety Matters.

I first visited the BW Physical Therapy clinic in early 2016 to see if I could regain the proper function of my left arm after having damaged my shoulder over forty years ago. It was hurting more and more over the last year and so I arrived to embark upon four weeks of intense physical therapy.

And it worked!

Ultimately, I cancelled the appointment to see the specialist surgeon.

The entire process was worthwhile as I not only gained a greater range of movement for the left side, I also learned what I need to do to maintain flexibility. It seems that on-going exercises are very important, even necessary.

Why did I feel compelled to write?

At least one of the physical therapist employed at this site has displayed certain behavior that seems problematic:

I recently slipped feet-first down a set of wooden stairs and injured my back during a move to the South Shore and subsequently was late driving to 850 Boylston, Chestnut Hill, from there.

Although I left about 50 minutes before the appointed time I was late, and this person refused to see me.

I was in severe back pain and needed treatment yet this one person, evidently, thought it wise to punish me by refusing to see me. He knew I had fallen. He knew I was injured.

He knew I was in pain.
At least he should have known because I told him.

This one incident has ruined my perception of this place. The perception I had of it (that of healing and my getting better) was ruined by this one person’s quick decision… his response to my being nine minutes late.

As I reflect on it all I can only say that it seems that I failed to perform properly for him…. granted I was late, yet, am I wrong to think that they are there to serve me, the patient?

Standing there in Suite 200, 850 Boylston, I was both injured and in pain.

It seems clear to me now that the ego of one of the PT people at this address, working for this company, has brought me to this page in order to proclaim both the good and the bad experiences I took away from the events I encountered in this one part of the BW system.

It’s a shame that this happened.
Until 10:39AM of that day I HAD nothing but GOOD things to say.

I am compelled to write as I truly feel that a correction is needed!

The patient is not there to serve the service provider. No.

The service provider is there to serve the patient.
This is NOT what I am paying for.

I refuse to pay Brigham and Women’s Hospital for this breach!
BWH, you can deal with this person.

I am sorry to hear about your experience. Thank you so much for taking the time to write. Brigham and Women’s Hospital is committed to providing the safest, highest quality, and most satisfying care possible.
I would like to connect you directly with our patient family relations group to help. We take all patient concerns very seriously and we would greatly appreciate the opportunity to talk with you, learn from your experiences and improve.
Please contact patient family relations at 617-732-6636.
Thank you again,
Karen